[00:00:00] Stacey Richter: Here's a question I have heard more than once. What is a practical, speedy way to assess whether a TPA (third-party administrator) is truly independent and willing to protect the plan's interests. This plan sponsor's interests versus being captive to, for example, network contracts or carrier relationships or other conflicts of interest? What's an easy tell that can give you an answer fast?
After being posed this question, I knew the perfect person to call to get an answer, and that perfect person would be Kimberly Carleson from US Beacon, the CEO of US Beacon.
My name is Stacey Richter. This is Relentless Health Value. Thank you so much for being here. Thank you also so much to those of you who have financially supported the podcast and to everybody who has taken it upon yourselves to leave a tip in the tip jar or who has supported us in other ways.
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And with that, here is my Ask Me Anything with Kimberly Carleson.
Kimberly Carleson, welcome to Relentless Health Value.
[00:01:27] Kimberly Carleson: Thank you for having me, Stacey. It's a pleasure always.
[00:01:31] Stacey Richter: Today we have an Ask Me Anything, and I'm just gonna paraphrase. What is a practical, speedy way to assess whether a TPA I guess an ASO, but the question I think is more specifically about a third-party administrator, a TPA. And for more on this, go back and listen to the episode with Claire Brockbank that talks about the difference between a TPA and an ASO.
But let's talk about a TPA, whether they are truly independent and willing to protect a plan's interests, like whether interests are aligned here, versus whether the TPA (the third-party administrator) is kind of maybe too great of a degree being sort of captive to the network contracts or carrier relationships that that TPA may have.
Let's just start at the top here. Is there one kind of like one question to rule them all, one tell to rule them all? Like, how do you, how would you assess whether it's, this TPA is, like, independent, or whether the TPA, mm, may have, may find themselves running up against other interests?
[00:02:45] Kimberly Carleson: A few misaligned incentives maybe.
I think the one way to tell is you'd ask them one question, and you say, "Can we have someone come in and independently review our claims?"
If they say, "We have network contracts that restrict that," then you know that is a red flag, and they are not truly independent. They are working for the network, not the plan.
So the one way to tell is, are they gonna allow independents on review for their claims? Are they gonna allow you all the data? Are they gonna allow you your billed, your paid, and your allowed charges? Are they gonna allow you to see all the claims data?
Those are things that if they have any hesitation on, you know they are not truly independent.
[00:03:30] Stacey Richter: Okay, so let's parse this down. It sounds like your big kahuna question is, "Will you allow someone to come in and audit the claims that you're paying on my plan's behalf? Will you let someone come in and take a look at these claims?"
If they say "Yes", if they say, "Yes, sure," most likely it's like: No further questions, your Honor. You know what I mean?
[00:03:57] Kimberly Carleson: Sealed and done.
[00:03:58] Stacey Richter: It's probably, if there's no hesitation there.
Yeah, I can see why you pick that as a big tell, because there's a lot of things that are sort of implied if they're okay with an independent audit. One of them is, as you mentioned, access to data. Because you can't do an audit unless you have access to the data.
But the other thing that I'm hearing as part of this is that the TPA would've had to have ensured that there's no blocking language in the contracts, which is another thing that we hear a lot about.
[00:04:31] Kimberly Carleson: That's right. So a lot of times it will state that, you are not allowed to access the data, you're not allowed to contact their providers.
They have a lot of things in the contract that don't allow the plan to independently review claims. So that is one of the big things that you wanna make sure that your contracts do not prohibit you from anything of reviewing independently on your data and your claims and your payments that you make.
[00:04:58] Stacey Richter: Yeah. And as we're talking about, you know, like the question that was asked here is, you know, how do you make sure that a TPA is truly independent and not beholden to a network that they may... You know, like, the thing with a TPA is that you're kind of bringing your own network, or at least that's the idea there, right?
Like, you have the third-party administrator, and then the network is kind of separate. But if the TPA is working so closely with these networks that they have contracts that they're beholden to the network such that the contractual language prohibits certain things from happening, then, you know, I can definitely see what you're saying.
That's a really good tell that the TPA has, it may not be quite as independent as you may like as a plan sponsor who's trying to figure out how to create your own self-funded plan.
[00:05:51] Kimberly Carleson: That's right. So when I heard of independent TPAs, I thought, Oh, great. This is, we're gonna be able to be away from the BUCA. We're not gonna have these restrictions. But really it's just sometimes a TPA that's renting their network and still the same actions as what any BUCA would be. So they're beholden to that network.
You wanna make sure if that TPA does not work for you, it's beholden to the network and it's still handcuffed, so you've gotta find one that is truly independent and is able to fight for you.
[00:06:23] Stacey Richter: Yeah. I, what I'm thinking about here, Kimberly, and this is a really interesting conversation, but it just underlines for me the idea that irrespective of what someone calls themselves, like, there's plenty of partners, vendors, transparent … out there and it sorta doesn't matter in a way how they classify themselves.
It's still really important to do the due diligence here and validate what is heard, 'cause talk is cheap, and there's a really big difference between…
[00:07:00] Kimberly Carleson: People use a lot, right, people use a lot of words to make themselves sound transparent, independent, that sound really good and catchy and make you think that you are gonna have control of your plan when in reality, those words are used to pull you in. And they're tricky, so you always wanna follow through.
[00:07:19] Stacey Richter: Just kind of in summary, I think you gave a really practical answer here, Kimberly, that I think a lot of people are gonna... It's kind of a, yeah, like a big kahuna of a a tell. If you wanna figure out if a TPA is truly independent, and you simply ask, "Can I have an independent claims audit? Can I bring in my own people to audit, because I'm trying to make my own self-funded plan?"
Like, I've heard Jonathan Baran calling it self-funded in name only. You know what I mean? Like, I really wanna make my own self-funded plan here. That's the whole reason I'm going self-funded. I wanna do my own thing. I wanna bring in my own vendors. And if you say to that TPA, "Well, great, can I bring in my own auditor?"
And they're like, "Nope," well, that's a pretty good sign to dig in further.
[00:08:05] Kimberly Carleson: That's the red flag. That's the red flag right there. If they don't want... There's something they don't want you to see if you can't bring in who you want to bring in.
[00:08:13] Stacey Richter: Thank you so much, Kimberly Carleson, for answering this question and being on Relentless Health Value today.
[00:08:17] Kimberly Carleson: Thank you, Stacey. I appreciate it.